Staff Medical Information & Release Form Summer 2025
Your Name:
*
First Name
Last Name
JP Staff Position
Please Select
CD- Camp Director
ACD- Assistant Camp Director
PD- Program Director
WL- Worship Lead
TC- Tool Site Coordinator
TCA- Tool Coordinator Assistant
RL- Recreation Lead
ML- Media Lead
J.Staff
SL- Site Leader
KS- Kitchen Staff
SI- Summer Project Coordinator
Do you currently have auto insurance?
*
Please Select
Yes
No
I will not be driving
Please check the week(s) you are serving
*
June 21 - 28
July 5 - 12
July 12 - 19
July 19- 26
E-mail
*
Cell Phone
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contacts
Home Phone
Primary Contact Name
Immediate Family: Father, Mother, Husband, Wife, etc
Primary Contact Cell
Secondary Contact Name
Immediate Family: Father, Mother, Husband, Wife, etc
Secondary Contact Cell
Name of Emergency Contact (other than parent(s):
Grandparent, neighbor, family friend, etc
Emergency Contact Phone:
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Please list any food allergies or dietary concerns:
Allergies or Medical Conditions we should be aware of (check all that apply):
Asthma
Convulsions
Diabetes
Fainting Spells
Insect Stings
Allergies
Allergic reaction to medicines?
Yes
No
If yes, please list all medicines you are allergic to:
Psychological issues (i.e. cutting, eating disorder, depression)?
Yes
No
If "yes" to the previous question, please explain:
Other medical issues we should be made aware of:
Current medications you are taking that we need to be aware of:
Please note: The Jeremiah Project is not responsible for dispensing medicine. That responsibility rests solely with the staffer.
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Insurance Information
Name of insurance company:
Name of policy holder:
Policy or Group #:
Other Insurance Information:
Electronic Signature (Staffers 18 years and older)
For staffers 18 and older (for staffers under the age of 18, please see below): In the case of a medical emergency, I understand that every effort will be made to contact the parent(s) or guardian(s) of this person. In the event that neither the parent(s) or guardian(s), nor the emergency contact person listed above, can be located, I hereby give permission for the Jeremiah Project Camp Director or other authorized Jeremiah Project representative to select a physician, to hospitalize, to secure proper treatment for, and to order injection, anesthesia or surgery for me. Jeremiah Project insurance serves as a secondary coverage. I release the following from any liability in the event of an accident or injury en route to, during and/or returning from Jeremiah Project activities, both work and recreational related: The Jeremiah Project, Inc. and all staff persons connected within, all adult leaders, chaperones, and/or churches.
Electronic signature of staffer 18 and older. By typing your name you are agreeing to the above.
Electronic Signature (Staffers under the age of 18)
My child has my permission to attend The Jeremiah Project outreach ministry camp including all trips to project locations associated with this ministry. In the case of a medical emergency, I understand that every effort will be made to contact my child's parent(s) or guardian(s). In the event that neither I, nor the emergency contact person listed above, can be located, I hereby give permission for the Jeremiah Project Camp Director (or other authorized Jeremiah Project representative), or my church group leader to select a physician, to hospitalize, to secure proper treatment for, and to order injection, anesthesia or surgery for my child. (This information will be required in the event that the participant listed above is taken for medical treatment.) Jeremiah Project insurance serves as a secondary coverage. I release the following from any liability in the event of an accident or injury en route to, during and/or returning from Jeremiah Project activities, both work and recreational related: The Jeremiah Project, Inc. and all staff persons connected within, all adult leaders, chaperones, and/or churches.
Name of Child:
Electronic signature of parent of staffer who is under the age of 18. By typing your name, you are agreeing to the above.
Please confirm the accuracy of your answers before submitting this form!
Submit
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